1. (a) F (b) T (c) F (d) T (e) T

In 2008 the total number of abortions in E&W was 195,296, compared to 198,499 in 2007, a fall of 1.6%.

Medical abortions performed in the E&W have indeed increased to 38% of the total in 2008 compared to 12% in 2001. In 2008 73% of all abortions were under 10 weeks gestation compared to 70% for the same gestation in 2007. This figure is taken as one measure of accessibility of abortion services. A consequence of increasing the involvement of nurses in abortion care provision in the UK appears to be improved access to early medical abortion. There has been an increase in medical abortions relative to surgical abortions in the UK over the past decade. The proportion of medical abortions has more than doubled in the last five years.

2. (a) T (b) F (c) T (d) T (e) F

Each year, there are an estimated 19 million unsafe abortions worldwide. Around 7,000 women die each year as a result of illegal, unsafe abortions, mostly in developing countries, making this a significant cause of maternal mortality. In addition, annually an estimated eight million women experience complications related to unsafe abortion that need medical treatment. These estimates have hardly changed over the past ten years. Data suggests that even though globally, the overall abortion rate has declined, the proportion of unsafe abortion is on the rise, especially in the developing world.

3. (a) T (b) F (c) F (d) F (e) T

Abortion indeed remains illegal in Northern Ireland where the 1967 Act does not apply. Abortion is legal up to 24 weeks gestation under the 1967 Abortion Act (as amended by the Human Fertilisation and Embryology Act 1990). Nurses are not permitted under the 1967 Act to sign the legal forms for authorisation of abortion. The signatures of two medical practitioners are necessary for the legal authorisation of abortion. Premises undertaking the use of Mifegyne for medical terminations have needed a license from the Department of Health since the drug was licensed in 1991.

4. (a) F (b) F (c) T (d) T (e) T

The law relating to who can provide abortions varies greatly between different states in the USA. In 2004, it was estimated that APCs were allowed to provide medical abortions in 14 states and surgical abortions in only six. Though abortion has been legal in India for over 30 years, limited establishment of licensed premises, poor infrastructure, a physician-only policy, poor regulation and ignorance of the law by both providers and women has resulted in poor access to abortions, especially in rural areas. One in seven maternal deaths in India is currently attributable to unsafe abortion. Two cohort studies in the United States as well as one randomised controlled trial in South Africa and Vietnam have found that complication rates in first trimester surgical/manual vacuum aspiration abortion procedures done by non-doctors and doctors are comparable. There is no abortion law in Canada which means that abortions like any other medical procedure can be carried out based purely on clinical need. Hence there is no upper gestational limit on abortions. In both Belgium and Germany, women are required to obtain counselling and wait for a certain period before having the abortion.

5. (a) F (b) F (c) F (d) T (e) F

Worldwide, the lifetime average is about 1 abortion per woman. In the United States, 1 in 3 women will have an abortion by the age of 45 years. The lowest rates in the world are in Western and Northern Europe, where abortion is accessible with few restrictions. In the Netherlands, a country with some of the world’s most liberal abortion laws; the ratio is closer to 10 per cent. A woman’s likelihood of having an abortion is similar whether she lives in a developed or developing region but, due to population distribution most abortions occur in developing countries. In 2003, there were 26 abortions per 1,000 women aged 15–44 in developed countries compared with 29 per 1,000 in developing countries. Elective abortion is the most common surgical procedure among reproductive-aged women in the US, with 1.2 million elective abortions in 2005 and an abortion ratio of 22.4 abortions per 100 live-births. Contrary to common belief, most women seeking abortion are married or living in stable unions and already have several children. Brazil, where abortion is very restricted, has one of the highest abortion rates in the developing world. The Health Ministry estimates that 31 percent of all pregnancies end in abortion, mostly clandestine. At the end of the 1970s all Nordic countries introduced liberal abortion legislation; obligatory sex education was introduced in schools and measures were taken to improve access to contraceptives. The number of abortions decreased in all those countries after the introduction of the legislation. Belgium and the Netherlands have had the same experience.

6. (a) T (b) T (c) T (d) F (e) T

While some national constitutions have included wording protecting life from conception, International courts and tribunals have been silent on the difficult philosophical issue of when life begins. However, the language of the various treaties is generally understood not to include an unborn fetus in references to every human being or everyone or every person. The status of the fetus in human rights law i.e. whether or not a fetus is a person recognized to have a right to life according to article 6 of the ICCPR has never been a central issue in cases of abortion considered by any of the UN human rights bodies. In fact, the right to the highest attainable standard of health has not been one of the key rights used to date in the UN Human Rights Court in determining the right to access safe abortion. In June 2009 there was a United Nations resolution on the recognition of maternal mortality as a violation of human rights, a landmark decision in highlighting the need to urgently address unsafe abortion and prevention of unintended pregnancy. There are multiple references to support that the right to conscientious objection is not absolute, though it should be respected. Many believe that reproductive rights are somewhat recent but they can be traced back even to the Universal Declaration of Human Rights and are defined as early as the UN International Conference on Human Rights in Tehran in 1968.

7. (a) T (b) T (c) T (d) T (e) F

Legal abortion generally goes hand in hand with increases in access to contraception. The lowest abortion rates in the world are in Western and Northern Europe, where abortion is accessible with few restrictions. Decreases in abortion rates globally have been driven largely by the recent changes in Previous Soviet Bloc countries and China with respect to improved accessibility to contraception. Between 1995 and 2003, the abortion rate fell from 69 to 45 per 1,000 in the Russian Federation, from 56 to 36 in Estonia and from 51 to 22 in Bulgaria. Women of means have been documented to seek safe abortion either within their country or outside in the face of restrictive abortion legislation or significant costs of accessing safe and legal abortion. This has been documented for Ireland, Egypt and most well known, Romania during the Ceausescu regime. In 2004, the United Nations Committee Against Torture called for an end to the extraction of confessions for prosecution purposes from women seeking emergency medical care as a result of illegal abortion. In addition concerns have been expressed by the UN Committee against torture and the UN Committee on ESCR, the Convention of Belém do Pará was clear that Nicaragua had breached the Convention based on its new legislation that does not permit abortion even to save the life of the woman. The most recent ruling on this issue comes from Colombia in 2008 in a case of a 13 year old girl who, with her mother’s support, had sought abortion after rape and though she met the legal criteria, the designated institution claimed the right to conscientious objection, claiming it could find no-one prepared to provide the abortion. The institution was fined and among the rulings made was that conscientious objection is personal not institutional. A study by Faundes et al showed that the closer the relationship to the obstetrician gynecologist, the more likely they would support a request to facilitate access to abortion in Brazil, where the law is restrictive but abortion is very common. This finding was independent of the religious affiliation of the physician. Of those who described religion as very important to them 26.1% would assist a patient with an unwanted pregnancy to have an abortion. If the unwanted pregnancy affected the physician or the physician’s partner, 68.7 % would have or assist in access to an abortion.

8. (a) T (b) F (c) T (d) F (e) T

The positive correlation of social disadvantage and teenage pregnancy permeates all the literature. More than one third of teenagers intend to become pregnant. There is an incremental rise in conception rate each year through adolescence. The figure in England & Wales for 2007 rises from 5.8 per 1000 at age 14 to 96.8 per 1000 at age 19. The United States has the highest rate of teenage births among industrialized nations. That children born to teenage mothers have an increased risk of accidents has been shown by a group at the University of Southampton.

9. (a) F (b) F (c) T (d) F (e) T

There is no evidence to support either a or b. Dropping out of school prior to the index pregnancy as an association has been shown by at least four different studies. It is the opposite: having planned the first pregnancy is a predictor of repeat adolescent pregnancy. Choice of oral contraception rather than long-acting reversible contraception as a predictor has been shown by at least four different studies.

10. (a) F (b) T (c) F (d) F (e) T

Most studies have been carried out in the USA. These studies are mostly among deprived communities and so conclusions may not be generalizable to less deprived American communities or to other countries.

Individualized counselling being more effective has been shown by Klerman. Home visits by nurses have been shown to be effective. One of the main features of teenage pregnancy is lack of enjoyment of school. Absence from school is an important predictor of repeat adolescent pregnancy. Some programmes are ineffective and some have higher pregnancy rates in the intervention group. Combined mother and infant care has been shown to be beneficial in at least five different studies.

11. (a) F (b) F (c) T (d) F (e) T

Copper is toxic to sperm and ova, and the principle mode of action is inhibition of fertilisation. PID in an IUD user should be treated with antibiotics, with appropriate partner notification, but the IUD can usually be left in situ. An IUD can be inserted up to 5 days after earliest predicted day of ovulation i.e. up to day 19 of a 28 day cycle. When an IUD is inserted in a woman aged 40 or above, it can be retained until after the menopause. This may well be beyond the licenced duration for the device. The first line banded devices contain 380mm ² .

12. (a) F (b) T (c) F (d) T (e) T

Implanon contains 68mg etonogestrel. Implanon is immediately effective up to day 5 after abortion.

Implanon is categorised as UKMEC 2 with a history of VTE i.e. the benefits of the method outweigh the risks. Implanon is categorised as UKMEC 1 in women with GTD. The cost effectiveness analysis by NICE has shown that all LARC methods are more cost effective than COCP by end of one year of use.

13. (a) F (b) F (c) F (d) T (e) T

MHRA and FSRH advise that the risks and benefits of continued DMPA use should be assessed every 2 years, but no upper limit of use is set. St John’s Wort is a mild liver enzyme inducer. However, the efficacy of DMPA is not affected by liver enzyme inducers. Several studies have demonstrated an increase in weight with DMPA use, especially in those with a higher baseline BMI. Although there is conflicting evidence suggesting an adverse relationship between DMPA use and BMD, there is no evidence of increased fracture risk. The failure rate is less than 4 per 1000 users over 2 years.

14. (a) F (b) T (c) T (d) F (e) T

The method of termination during the first trimester does not affect emotional adjustment or psychological experiences after the procedure. Negative psychological predictors are very similar post abortion and childbirth. A history of pre existing psychiatric illness is indeed strongly predictive of those women at greater risk of mental health problems after an abortion. Denial of access to abortion is a good predictor of worse psychological outcome. The systematic review in 2008 reported that women having an abortion for fetal anomaly are more likely to experience depression and anxiety than those delivering a health child, but with a risk similar to women having a late miscarriage.

15. (a) T (b) F (c) F (d) T (e) T

Women at higher risk for negative emotions several years after an abortion included those with a prior history of mental health problems (depression, self harm, psychosis), younger age at the time of the abortion, low perceived social support for their decision and greater personal conflict about abortion.

16. (a) T (b) T (c) T (d) T (e) T

A major confounder in studies where history of abortion is self reported is that of under-reporting due to the stigma associated with termination of pregnancy. The general population of women who deliver a baby are not an appropriate comparison group since women who plan a pregnancy and deliver a wanted baby may differ in important characteristics from women choosing an abortion. Few studies assessed or adequately controlled for confounding factors such as the co- occurrence of unwanted pregnancy with adverse circumstances and adverse circumstances with mental health problems.

17. (a) F (b) T (c) F (d) F (e) F

There is very little evidence to support termination of pregnancy as a cause of secondary infertility, certainly not in all cases. Only two studies, both of them based in Greece where abortion is illegal and therefore likely to be more associated with pelvic infection, have reported an association. There is an increased risk of secondary infertility in cases of pelvic sepsis which can lead to adhesions and tubal infertility. Neither of the two systematic reviews support (c) and (d). As stated earlier, no association has been found with secondary infertility and therefore no dose response effect has been demonstrated.

18. (a) T (b) F (c) F (d) F (e) F

The available literature suggests that there is an association between induced abortion and placenta praevia. Systematic reviews with meta-analyses have reported a strong association between IA and placenta praevia. This is likely to be the result of multiple curettages following IA. There is some controversy, however, with regard to any association between IA and abruption. Earlier studies have described an association between miscarriage and IA, but recent meta-analyses have not found any such association. Most studies that have found an association between IA and PTB have failed to discriminate between spontaneous and induced preterm birth. Induced preterm birth may be the result of clinical decisions based on maternal complications which themselves could be linked to IA. Only two original papers performed a sub-analysis, distinguishing spontaneous from induced preterm birth. This sub-analysis did not change the results of either study. There appears to be an association between dilatation and evacuation and low birth weight in subsequent pregnancies, but not with vacuum aspiration. Very few studies have looked at the relationship between medical IA and low birth weight, but those that have, have failed to find any association. Induced abortions may reduce the risk of pre-eclampsia in a subsequent pregnancy. However, the protection does not appear to be as high as that conferred by a full term pregnancy.

19. (a) F (b) T (c) T (d) T (e) F

There seems to be some evidence to support the hypothesis that normal pregnancies that are terminated in early pregnancy may stimulate immunological changes that reduce the risk of pre-eclampsia in a subsequent pregnancy. This reduction in risk seems to have a dose-response effect. However, the protection does not appear to be as high as that conferred by a full term pregnancy.

20. (a) F (b) T (c) T (d) F (e) F

Care is not equitable throughout the UK as is evidenced by the spread of gestations at the time of abortion in different primary care organisations and evidence reported to the review of the National Sexual Health Strategy. Abortion is illegal in Northern Ireland so care closer to home is unachievable in the Province. Self referral is an option but not one offered by all services. It is offered by those contracted out to do so by independent providers such as the British Pregnancy Advisory Service and Marie Stopes International.

The abortion statistics of both England and Wales and Scotland show an increase in abortion at early gestation. This has tied in with the increased provision of early medical abortion. 38% of all abortions in England and Wales 78.4 in Scotland in 2008 were early-medical abortions. The complication rates of haemorrhage, uterine perforation and cervical trauma falls with gestation. Failed abortion and continuing pregnancy is highest in surgical abortions at low gestation, but are reduced if the procedure is carried out by manual vacuum aspiration to a strict protocol. Statistics from both England and Wales and Scotland show that abortion rates above 13 weeks are fairly static. Research indicates this is due to many issues of which poor access is a minor player.

21. (a) T (b) T (c) F (d) F (e) T

Contraceptive care is an essential component of abortion care and has been recognised as such. This is commonly provided in community and primary care. The NHS Operating Framework and Contract for 2009/10 requires PCTs to approve arrangements for abortion services to improve access for women using their services to a full range of contraception, including follow up arrangements for women who do not receive contraceptive advice or treatment at the time of the abortion. Pre-assessment can take place anywhere with suitable facilities and appropriately trained staff. Specialist training currently takes place in the main in Acute Trusts. STIs and partner notification should be managed by the specialist providers, the GU medicine clinics and the emergent level 2 primary and community services. Abortion services ideally should screen for Chlamydia and HIV because the risks leading to unwanted pregnancy are those which also lead to infection transmission. Other STIs of high prevalence in that location should also be screened for. Visual identification of products of conception is an accurate way of confirming procedure completion. Alternatives are scanning or ßHCG estimation. All are possible in any appropriately staffed and equipped setting.

22. (a) F (b) F (c) T (d) T (e) F

Repeating pregnancy tests under any circumstances, especially by sending off to a lab which is expensive in time, money and patient anxiety is not cost effective. Should a confirmatory pregnancy test be required, an on-the-spot urine test with a commercially available high sensitivity stick is quite sufficient. Good health care promotes equality and eliminates discrimination. There should not be restricted access to any woman eligible for NHS care on the grounds of age or personal circumstances (such as marital status or parity) as there currently is in some primary care organisations. Abortion services give an opportunity to offer comprehensive care including access to established national screening programmes such as under -25 Chlamydia screening and cervical cytology, and local programmes such as offering HIV screening to all women attending abortion services. Clinicians with conscientious objection to abortion do not have to participate in any aspect of routine abortion care if it conflicts with their religious or moral beliefs but they must make the care of the patient their first concern. This stance with information on alternative services should be displayed within the practice premises and be in the practice descriptor if in primary care. If a patient does request abortion care, the doctor must explain the religious or moral conflict to the patient and tell them they have the right to see another doctor and make sure they have sufficient information to exercise that right. The clinician must ensure that arrangements are made for another suitably qualified colleague to take over their role. As yet, the Secretary of State for Health has not seen fit to agree to address a class of place for early surgical abortion in a community setting, as he has for early medical abortion. Manual vacuum aspiration under local anaesthesia has been established safely in an outpatient setting in many countries leading to a reduction in waiting time, gestation and cost.

23. (a) T (b) F (c) F (d) T (e) T

ICPs are used as a tool to incorporate local and national guidelines into everyday practice and meet the requirements of clinical governance. All ICPs are supported by evidence-based guidelines and the RCOG clinical guidelines are quoted widely internationally as the gold standard of abortion care. The ICP makes explicit the standard(s) of care against which actual care can be judged. Deviations from this standard can be used to inform changes in practice and to assess the relationship between different interventions and individual patient outcomes. This, in turn, supports the management of clinical risk. ICPs are not intended to compromise clinical judgement and the pathway can be deviated from if there is a valid reason to do so. Clinical freedom is promoted based on the needs of the individual patient. Subsequent analysis of variations from the pathway provides information to the clinical team on the overall quality of care and allows modifications and improvements to be made to the content of the pathway. ICPs are dynamic documents, and change is to be expected as new evidence, clinical guidelines and treatment patterns emerge. Routine monitoring of ICPs and retrospective analysis of variations help to highlight areas of clinical risk and complete the clinical audit cycle. ICPs are patient focussed and view the delivery of care in terms of the patient journey. Only patients can capture what is needed from the patient perspective and through participation influence pathway development and content to meet the spectrum of patient needs appropriately.

24. (a) F (b) T (c) T (d) F (e) F

During the past ten years there has been increasing legislative interest in the possibility of fetal pain. In 2006 the US House of Representatives considered the Unborn Child Pain Awareness Act. The bill secured a majority but failed to obtain the two-thirds majority necessary to pass into law. Efforts at the State level have been more successful. At least 25 US States have considered fetal pain legislation and at least eight (Alaska, Arkansas, Georgia, Oklahoma, South Dakota, South Louisiana, Texas and Wisconsin) now have legislation requiring that women seeking abortions be informed of the possibility of fetal pain. Fetal pain has also been widely debated in Britain. The British MRC and RCOG have both issued reports on fetal pain and the issue of fetal pain was debated by the British Parliamentary Science and Technology Select Committee in 2008. There is, however, no British or European legislation that makes any direct reference to fetal pain. Beginning in the periphery, there are nerve endings that preferentially transmit noxious information. They are the free nerve endings that arise mostly from the peripheral termination of A-delta and C fibres. The free nerve endings are polymodal and can respond to non-noxious and noxious temperatures or mechanical stimuli. When activity in A-delta and C fibres gives rise to pain or behaviour associated with pain then they are labelled as nociceptors. Fibres that only respond in the noxious range are labelled as nociceptive specific while those that respond across the noxious and non-noxious range are labelled as wide dynamic range.

25. (a) T (b) F (c) T (d) T (e) T

The primary afferent A-delta and C fibres terminate on neurons in the superficial dorsal horn of the spinal cord. Ascending projections to the thalamus originate from the most superficial layer, known as lamina I, and project contralaterally in the spinothalamic tract (STT). Intracellular recordings from lamina I neurons revealed neurons with seemingly modality-specific responses. One class of neurons were nociceptive specific, responsive only to noxious pinch, heat or both. Another class were thermoreceptive-specific, responding only to non-noxious cooling. A final class were polymodal, responding to heat, pinch and cooling. The existence of lamina I neurons, with specific responses and distinct morphology, motivated the suggestion that there are dedicated pathways for pain and temperature detection.

26. (a) T (b) T (c) F (d) T (e) T

A series of neuro-imaging studies have demonstrated consistent activation of several cerebral structures during pain. These structures include the primary and secondary somato-sensory cortices and anterior cingulate, prefrontal and insular cortices. In combination, these structures are thought to coordinate defensive reactions and generate the sensory and unpleasant feelings associated with pain.

27. (a) F (b) F (c) T (d) T (e) F

The first evidence for an intact nociceptive system in the fetus emerges at about 8 weeks gestational age (GA). At this stage, touching the peri-oral region will result in movement away, indicating the presence of sensory receptors and, at least, spinal or brainstem mediated reflex action. Some claim that by 8 weeks GA there are connections from the periphery and through the spinal cord to the thalamus but these claims are yet to receive any peer-reviewed verification. The possibility of functional neurons from the periphery, into the thalamus and into the outer layer of the developing cortex places a lower time limit for fetal pain at around 11 weeks GA. Between 12 and 18 weeks the formation of the sub-plate begins and the first projections from the thalamus into the sub-plate appear. The sub-plate is a transient brain structure formed directly underneath the developing cortical plate. Neurons arrive in the sub-plate and are held for several weeks until the cortical plate becomes growth permissive and facilitates neuronal invasion of the cortical plate. The relocation of neurons from the sub-plate to the cortical plate begins around 24 weeks GA and is extremely rapid from about 34 weeks. Afterwards the extracelluar matrix and other growth related and guidance molecules disappear leading to the dissolution of the sub-plate.

28. (a) T (b) F (c) T (d) T (e) T

The majority of women in the reproductive age group in the UK are using at least one form of contraception. In 2003/2004, almost a quarter of women were relying on sterilisation (11% female and 12% male partner), 25% were using a contraceptive pill, and 23% the male condom. The long-acting reversible contraceptive methods (LARC) were used by less than 10% of women, with 4% using the copper intrauterine device (IUD) 3% the progestogen-only injectable contraceptive (POIC) or implant, and 1% the progestogen-only intrauterine system (IUS).

29. (a) F (b) T (c) T (d) T (e) T

Contraceptive methods vary in effectiveness, and effectiveness in practice (typical use) varies from perfect use. The LARC methods and sterilisation show least variation between typical and perfect use. The implant and intrauterine methods once inserted require no further action on behalf of the user, other than to return for method replacement at the end of the licenced period of use. The injectable method, although still very effective, depends on the user returning regularly for repeat injection. The risk of pregnancy in the first year of use for oral contraceptive users varies greatly for perfect use (0.3%) compared to typical use (8%). A number of studies have shown that many oral contraceptive users have poor compliance with the method. In one study, almost half (47%) of women reported missing one or more pills per cycle. Another study, which used electronic diaries to measure compliance, demonstrated that 63% of women missed at least one pill in the first cycle of use, and 74% missed in the second cycle. Likewise, even greater variation exists for methods which on motivation with every act of intercourse, such as condoms or withdrawal.

30. (a) T (b) T (c) T (d) F (e) T

The current NICE guidance advises clinicians that women requiring contraception should be offered a choice of all methods, including the LARC methods. This guideline defined LARC as reversible methods of contraception, which require administration less than once per month. In addition, an economic analysis demonstrated that all LARC methods are more cost effective than the combined oral contraceptive pill even at one year of use. Of particular note, it was also demonstrated that increasing the uptake of LARC will decrease the numbers of unintended pregnancies. Thus there exists the potential to reduce the number of abortions, by increasing the general uptake of LARC, but in addition, to reduce the repeat abortion rate by targeting women presenting for their first abortion. This is a reasonable assumption but has not been actually demonstrated.